- Email: [email protected]
Combined group and individual model for postbariatric surgery follow-up care
Surgery for Obesity and Related Diseases 8 (2012) 220 –224
Integrated health article
Combined group and individual model for postbariatric surgery follow-up care Paul A. Lorentz, M.S., R.N., R.D.*, James M. Swain, M.D., Margaret M. Gall, R.D., Maria L. Collazo-Clavell, M.D. Mayo Clinic, Rochester, Minnesota Received May 1, 2011; accepted September 1, 2011
Abstract
Background: The prevalence of bariatric surgery in the United States has increased significantly during the past decade, increasing the number of patients requiring postbariatric surgery follow-up care. Our objective was to develop and implement an efficient, financially viable, postbariatric surgery practice model that would be acceptable to patients. The setting was the Mayo Clinic (Rochester, MN). Methods: By monitoring the attendance rates and using patient surveys, we tested patient acceptance of a new, shared medical appointment practice model in the care of postbariatric surgery patients. Efficiency was assessed by comparing differences in time per patient and total provider time required between the former and new care models. Individual-only patient/provider visits were replaced by combined group and individual visits (CGV). Results: Our CGV model was well-attended and accepted. The patient attendance rate was ⬎90% at all postoperative follow-up points. Furthermore, 83%, 85.2%, and 75.7% of the 3-, 6-, and 12-month postbariatric surgery patients, respectively, responded that they would not prefer to have only individual visits with their healthcare providers. The CGV model also resulted in greater time efficiency and cost reduction. On average, 5 patients were seen within 4.9 provider hours compared with 10.4 provider hours with the individual-only patient/provider visit model. Furthermore, the average billable charge for the CGV model’s group medical nutrition therapy was 50 – 64% less than the equivalent individual medical nutrition therapy used in the individual-only patient/provider visit model. Conclusion: Shared medical appointments have a valuable role in the care of the postbariatric surgery population, offering a time- and cost-effective model for healthcare provision that is well-accepted by patients. (Surg Obes Relat Dis 2012;8:220 –224.) © 2012 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Keywords:
Bariatric; Shared medical appointment; SMA; Follow-up care; Practice model
The number of bariatric surgeries performed in the United States has increased significantly during the past decade, resulting in an increasing number of patients requiring postbariatric surgery surveillance [1]. Given the sustained level of demand for this service and the heightened level of scrutiny to control healthcare costs, the develop*Correspondence: Paul A. Lorentz, M.S., R.N., R.D., Mayo Clinic, 200 First Street South West, Rochester, MN 55905. E-mail: [email protected]
ment of practice models that optimize patient care in an efficient, financially viable manner is warranted. Alternatives to the traditional one-on-one visit between medical providers and their patients have been in place since the mid-1990s. Edward Noffsinger [2], a psychologist and the director of clinical access improvement at the Palo Alto Medical Foundation, introduced the healthcare field to the shared medical appointment (SMA) model. In essence, SMAs allow multiple patients with similar medical needs to be cared for simultaneously. Most often,
1550-7289/12/$ – see front matter © 2012 American Society for Metabolic and Bariatric Surgery. All rights reserved. doi:10.1016/j.soard.2011.09.013
Models for Postbariatric Surgery Follow-up Care / Surgery for Obesity and Related Diseases 8 (2012) 220 –224
a portion of the SMA is conducted in a group setting, in which a healthcare provider reviews the medical information applicable to all participants. The aspects of care unique to a particular patient can be addressed during the individual (one-on-one) portion of the SMA. Although shorter in length, the individual component in an SMA setting is more focused and succinct than in a traditional one-on-one visit [3]. SMAs offer many benefits beyond improved efficiency. These include adding universality to the patient experience, promotion of imitative behavior and role modeling among patient peers, the opportunity to provide greater breadth and depth of the care topics reviewed, and a setting in which the patient peers and loved ones can offer a support system among themselves [4]. The benefits associated with SMAs extend beyond the patient. Care providers, physicians, and allied health staff alike are able to practice in a way that reduces monotony and educational redundancy. Because of the efficiencies of such models, providers are able to see more patients within a given period (improved clinical access), while reducing the cost-per-patient burden [4,5]. There are several different models of SMAs. Three of the more well-known SMA models include drop-in group medical appointments, cooperative healthcare clinics, and physical shared medical appointments [2,3,5]. Determining the ideal model depends largely on the practice setting, the population of patients served, and the overarching goals of the healthcare team. We developed a new practice model for our postbariatric surgery population, incorporating an SMA model. Our primary goal was to optimize patient care by using the expertise of the multidisciplinary team in a more efficient, financially viable manner that was acceptable to both patients and providers.
Methods Within our practice, we perform approximately 300 bariatric surgeries annually. These procedures and their relative percentage of the practice include Roux-en-Y gastric bypass (⬃70%), sleeve gastrectomy (⬃7%), biliopancreatic diversion with duodenal switch (⬃5%), laparoscopic adjustable gastric banding (LAGB, ⬃3%), and other (revisional surgery, conversion surgery, LAGB removal, and partial gastric resection, ⬃15%). Individual-only patient/provider visit model Historically, all patients who underwent bariatric surgery within our multidisciplinary practice were scheduled for follow-up visits at 4 intervals within the first year after surgery: 1 month postoperatively (surgeon and registered dietitian [RD]); 3 months postoperatively (endocrinologist and RD); 6 months postoperatively (endocrinologist, RD,
221
and psychologist); and 12 months postoperatively (endocrinologist and RD). The individual-only patient/provider visits (IV) held at 3, 6, and 12 months postoperatively were replaced with the combined group and individual visits (CGVs) at the same follow-up points. The 1-month postoperative visit (surgeon and RD) was kept as an IV. CGV model The inclusion criteria for the present study was Rouxen-Y gastric bypass, biliopancreatic diversion with duodenal switch, or sleeve gastrectomy, performed within our practice for the management of medically complicated obesity, from February 1, 2010 to March 31, 2011. The exclusion criteria were LAGB (primarily because of differences in the postoperative diet protocol), LAGB removal only, complex revisional surgery, extensive postoperative complications, the need for a language interpreter, significant hearing impairment, and/or a strong aversion to group settings. Logistics and facilities Telephone contact with the patients was attempted by the bariatric program coordinator (BPC) 24 – 48 hours before each scheduled CGV. If the BPC made direct contact with the patient, attendance at their upcoming CGV was confirmed. On average, 5 patients were scheduled for each CGV. On the day of the CGV, the blood work was completed, and the patients were escorted to a wheelchair-accessible group education room. Each patient was seated in a bariatric chair and provided a folder containing the relevant postbariatric surgery education materials. Group nutrition education was provided by a RD. The RD used electronic presentation methods, food models, packages, and labels and guided the group discussion to enhance the education provided. At the conclusion of the nutrition education, the BPC (RN, RD) provided group physical activity education. After the group education, the patients met individually with an endocrinologist and a RD. Therefore, 2 patients were being seen individually at any given time. During these individual slots within the CGV, the providers identified and cared for the unique needs of each patient. If a provider believed a particular patient would be best served with an IV in the future, this was arranged by the BPC (Table 1). Patients not being seen individually remained in the group education room with the BPC. During this period, an on-line survey was completed by all patients. The BPC also led and moderated discussions on various bariatric surgeryrelated topics, including applicable web-based tools, options for postoperative support, and considerations related to physical activity and mental health.
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P. A. Lorentz et al. / Surgery for Obesity and Related Diseases 8 (2012) 220 –224
Table 1 Data for individual patient/provider visits (former IV model) and combined group and individual patient/provider visits (new CGV model) Variable IV model Laboratory tests RD Endocrinologist Total time CGV model Laboratory tests Group nutrition education with RD Group physical activity education with BPC Alternating individual visits with RD and endocrinologist Total time
Time of day
Time needed/patient (min)
Total provider time for 5 patients (min)
7:30–8:00 AM 10:00–11:00 AM 3:00–4:00 PM 8.5 hr at clinic
5 60 60 125
25 300 300 625 (10.4 hr)
7:30–8:00 AM 8:30–9:15 AM 9:15–9.40 AM 9:50–11:30 AM 4 hr at clinic
5 45 25 20 95
25 45 25 200 295 (4.9 hr)
IV ⫽ individual-only patient/provider visit; RD ⫽ registered dietitian; CGV ⫽ combined group and individual visit; BPC ⫽ bariatric program coordinator.
Financial viability analysis To safeguard the financial viability of the CGV model, care was taken to balance the reduced per-patient charge with the volume of patients cared for. After a financial analysis was performed, it was determined that ⱖ4 postbariatric patients should be scheduled for each postbariatric CGV. In an effort to control the total time of the CGV and because of space limitations, the sessions were never scheduled with ⬎7 patients. Survey completion—patient acceptance and knowledge assessment
The remaining 113 patients (⬃34.9% of 324) had met ⱖ1 of the exclusion criteria and were scheduled for IVs. CGV model efficiency Our CGV model led to greater time efficiencies by reducing redundancies (primarily through group education) and by facilitating focused patient/provider visits. On average, 5 patients were seen within 4.9 provider hours compared with 10.4 hours using the IV model (Table 1). Financial considerations
Each CGV patient completed the on-line survey regarding their bariatric surgery process experience. The survey consisted of 10 multiple-response questions. Specifically, the questions were included to measure patient acceptance of the CGV model and to assess their level of understanding regarding the physical activity guidelines for the postbariatric surgery patient (Fig. 1).
Group nutrition education was charged as group medical nutrition therapy (MNT). Our institutional practice is to charge less per group MNT unit (1 U ⫽ 15 min) than for individual MNT units. For privately insured patients, the average billable charge for group MNT was 64% less than the equivalent individual MNT used in the IV model. For Medicare patients, the billable charge reduction was closer to 50%.
Attendance rate
Patient acceptance and attendance
The BPC maintained a spreadsheet of the CGV patients to monitor the attendance rates.
A total of 199, 142, and 38 postbariatric surgery patients at 3, 6, and 12 months after bariatric surgery completed our on-line survey, respectively. Of the 199 patients, 7 (⬍4%) were not comfortable using a computer to complete the survey. The patients were content with the group format, with 92.5%, 93%, and 88.6% of the patients at 3 months (184 of 199 surveys completed), 6 months (132 of 142 surveys completed), and 12 months (31 of 35 surveys completed) after bariatric surgery reporting being comfortable with the CGV setting, respectively (Fig. 1, question 4). The CGV model was well accepted, with 83%, 85.2%, and 75.7% of the patients at 3 months (161 of 194), 6 months (121 of 142), and 12 months (28 of 37), respectively. responding that they would not prefer to have only individual visits with their healthcare providers (Fig. 1, question 5). The rate of missed appointments/no-shows with the CGV model was also quite acceptable at ⬍10%.
Results Applicability of CGV model to bariatric surgery practice A total of 324 patients underwent bariatric surgery at our facility from February 1, 2010 to March 31, 2011. Of the 324 patients, 211 met the initial inclusion criteria for the CGV model. However, 12 patients (⬃3.7% of the 324) who met the initial inclusion criteria were unable to be seen using the CGV model for various reasons, including postoperative follow-up care pursued in their local area because of their great distance from our facility, the need to reschedule the CGV, or lost to follow-up. Therefore, 199 patients (⬃61.4% of 324) were included in the present study and were followed up using the CGV model.
Models for Postbariatric Surgery Follow-up Care / Surgery for Obesity and Related Diseases 8 (2012) 220 –224
223
Select Online Survey Quesons 4. Are you comfortable meeng in groups? o Yes o No If “No”, why not? (Free text box provided for paent comments) 5. Would you prefer to have only individual (rather than individual visits with some group sessions mixed in) visits with your healthcare providers? o No o Yes If “Yes”, please briefly explain (Free text box provided for paent comments) 8. Do you have any concerns which you would like addressed before leaving here today? o No o Yes If “Yes”, briefly explain (Free text box provided for paent comments) 10. Do you feel comfortable in knowing how much and what types of physical acvity are appropriate for you aer surgery? o Yes o No What types of physical acvity have you been doing since surgery? (Free text box provided for paent comments) Fig. 1. Select questions from on-line survey.
Knowledge assessment Patients attending the CGVs also expressed a sound understanding of the considerations relating to postoperative physical activity. Specifically, 98.5%, 98.6%, and 94.7% of the patients at 3 months (196 of 199), 6 months (140 of 142), and 12 months (36 of 38), respectively, reported feeling comfortable in knowing the quantity and types of physical activity appropriate for the postbariatric surgery patient (Fig. 1, question 10). Discussion To our knowledge, this is the first reported application of an SMA model to a well-defined postbariatric surgery patient population. Our new CGV model was suitable for the provision of postbariatric surgery follow-up care for approximately 60% of our patients. As previously reported, appropriate patient selection for participation in SMAs is a critical determinant of their success [6,7]. Our new CGV model was well-accepted, with most patients responding that they would not prefer to have only individual follow-up visits with their healthcare providers. Furthermore, the rate of missed appointments/no-shows was also quite acceptable, at ⬍10%. The positive effect of postbariatric surgery follow-up on patient outcomes has previously been reported [8,9]. The CGV model increased the efficiency by reducing the number of provider hours necessary to see a given quantity of patients. On average, 5 patients were seen within 4.9 provider hours compared with 10.4 hours with the IV model. Therefore, provider accessibility for other patients
within our practice was increased, more than offsetting the reduced group MNT charge of the CGV model. Financial viability was achieved with our average CGV size of 5 patients. Because of the lower group MNT charge, patients in the CGV model had a billable charge that was 50 – 64% less than that for similar patients seen in the IV model. These cost savings were passed on to the patients and the third-party payers. On the basis of our survey, ⬎94% of all patients seen in our CGVs reported feeling comfortable in knowing the amount and types of physical activity appropriate during the postoperative period. The importance of appropriate and adequate physical activity in the postbariatric surgery patient is well-established [10,11]. Developing and incorporating an SMA-based practice model, however, has some unique challenges and limitations. Significant resources are required to create and sustain such a model for a bariatric-related practice. An educational space equipped with bariatric accommodations (e.g., larger doorways, chair size, and seating capacity) is obligatory. Administrative staff are often needed to facilitate patient scheduling and to prepare the necessary educational materials. A BPC plays a pivotal role in the success of an SMA model for a bariatric-related practice. The BPC can provide the clinical judgment necessary to determine whether a given patient is appropriate for SMAs. During the actual SMA, the BPC facilitates the movement of patients through the SMA, in a coordinated and equitable fashion, and serves as a valuable patient resource. The BPC can also assist with post-SMA considerations, such as follow-up scheduling and
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P. A. Lorentz et al. / Surgery for Obesity and Related Diseases 8 (2012) 220 –224
medication prescription coordination and as a future point of contact for patients. Conclusion SMAs might have a valuable role in the care of the postbariatric surgery population, by offering a time- and cost-effective model for healthcare provision in a manner well-accepted by patients. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article. References [1] Livingston ED. The incidence of bariatric surgery has plateaued in the U.S. Am J Surg 2010;200:378 – 85. [2] Noffsinger EB. Running group visits in your practice. Newton, MA: Springer; 2009. [3] Carlson B. Shared appointments improve efficacy in the clinic. Manag Care 2003;12:46 – 8.
[4] American Academy of Family Physicians (AAFP). Group visits (shared medical appointments), 2005. Available from: http://www. aafp.org/online/en/home/practicemgt/quality/qitools/pracredesign/ january05.html. Accessed March 21, 2011. [5] Houck S, Kilo C, Scott JC. Improving patient care: group visits 101. Fam Pract Manag 2003;10:66 –78. [6] Masley S, Sokoloff J, Hawes C. Planning group visits for high-risk patients. Fam Pract Manag 2000;7:33–7. [7] Stein K. The group appointment trend gains traction: how dietetics fits into a new model of health care delivery. J Am Diet Assoc 2011;111:340 –53. [8] Shen R, Dugay G, Rajaram K, Cabrera I, Siegel N, Ren CJ. Impact of patient follow-up on weight loss after bariatric surgery. Obes Surg 2004;14:514 –19. [9] Pontiroli AE, Fossati A, Vedani P, et al. Post-surgery adherence to scheduled visits and compliance, more than personality disorders, predict outcome of bariatric restrictive surgery in morbidly obese patients. Obes Surg 2007;17:1492–7. [10] Evans RK, Bond DS, Wolfe LG, et al. Participation in 150 min/wk of moderate or higher intensity physical activity yields greater weight loss after gastric bypass surgery. Surg Obes Relat Dis 2007;3:526 –30. [11] Evans R, Wolfe L, Meador JG, Kellum JM, Maher JW. Gastric bypass surgery patients achieving suboptimal weight loss report less vigorous and total physical activity. Surg Obes Relat Dis 2009;5:S36.
Integrated health article
Combined group and individual model for postbariatric surgery follow-up care Paul A. Lorentz, M.S., R.N., R.D.*, James M. Swain, M.D., Margaret M. Gall, R.D., Maria L. Collazo-Clavell, M.D. Mayo Clinic, Rochester, Minnesota Received May 1, 2011; accepted September 1, 2011
Abstract
Background: The prevalence of bariatric surgery in the United States has increased significantly during the past decade, increasing the number of patients requiring postbariatric surgery follow-up care. Our objective was to develop and implement an efficient, financially viable, postbariatric surgery practice model that would be acceptable to patients. The setting was the Mayo Clinic (Rochester, MN). Methods: By monitoring the attendance rates and using patient surveys, we tested patient acceptance of a new, shared medical appointment practice model in the care of postbariatric surgery patients. Efficiency was assessed by comparing differences in time per patient and total provider time required between the former and new care models. Individual-only patient/provider visits were replaced by combined group and individual visits (CGV). Results: Our CGV model was well-attended and accepted. The patient attendance rate was ⬎90% at all postoperative follow-up points. Furthermore, 83%, 85.2%, and 75.7% of the 3-, 6-, and 12-month postbariatric surgery patients, respectively, responded that they would not prefer to have only individual visits with their healthcare providers. The CGV model also resulted in greater time efficiency and cost reduction. On average, 5 patients were seen within 4.9 provider hours compared with 10.4 provider hours with the individual-only patient/provider visit model. Furthermore, the average billable charge for the CGV model’s group medical nutrition therapy was 50 – 64% less than the equivalent individual medical nutrition therapy used in the individual-only patient/provider visit model. Conclusion: Shared medical appointments have a valuable role in the care of the postbariatric surgery population, offering a time- and cost-effective model for healthcare provision that is well-accepted by patients. (Surg Obes Relat Dis 2012;8:220 –224.) © 2012 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Keywords:
Bariatric; Shared medical appointment; SMA; Follow-up care; Practice model
The number of bariatric surgeries performed in the United States has increased significantly during the past decade, resulting in an increasing number of patients requiring postbariatric surgery surveillance [1]. Given the sustained level of demand for this service and the heightened level of scrutiny to control healthcare costs, the develop*Correspondence: Paul A. Lorentz, M.S., R.N., R.D., Mayo Clinic, 200 First Street South West, Rochester, MN 55905. E-mail: [email protected]
ment of practice models that optimize patient care in an efficient, financially viable manner is warranted. Alternatives to the traditional one-on-one visit between medical providers and their patients have been in place since the mid-1990s. Edward Noffsinger [2], a psychologist and the director of clinical access improvement at the Palo Alto Medical Foundation, introduced the healthcare field to the shared medical appointment (SMA) model. In essence, SMAs allow multiple patients with similar medical needs to be cared for simultaneously. Most often,
1550-7289/12/$ – see front matter © 2012 American Society for Metabolic and Bariatric Surgery. All rights reserved. doi:10.1016/j.soard.2011.09.013
Models for Postbariatric Surgery Follow-up Care / Surgery for Obesity and Related Diseases 8 (2012) 220 –224
a portion of the SMA is conducted in a group setting, in which a healthcare provider reviews the medical information applicable to all participants. The aspects of care unique to a particular patient can be addressed during the individual (one-on-one) portion of the SMA. Although shorter in length, the individual component in an SMA setting is more focused and succinct than in a traditional one-on-one visit [3]. SMAs offer many benefits beyond improved efficiency. These include adding universality to the patient experience, promotion of imitative behavior and role modeling among patient peers, the opportunity to provide greater breadth and depth of the care topics reviewed, and a setting in which the patient peers and loved ones can offer a support system among themselves [4]. The benefits associated with SMAs extend beyond the patient. Care providers, physicians, and allied health staff alike are able to practice in a way that reduces monotony and educational redundancy. Because of the efficiencies of such models, providers are able to see more patients within a given period (improved clinical access), while reducing the cost-per-patient burden [4,5]. There are several different models of SMAs. Three of the more well-known SMA models include drop-in group medical appointments, cooperative healthcare clinics, and physical shared medical appointments [2,3,5]. Determining the ideal model depends largely on the practice setting, the population of patients served, and the overarching goals of the healthcare team. We developed a new practice model for our postbariatric surgery population, incorporating an SMA model. Our primary goal was to optimize patient care by using the expertise of the multidisciplinary team in a more efficient, financially viable manner that was acceptable to both patients and providers.
Methods Within our practice, we perform approximately 300 bariatric surgeries annually. These procedures and their relative percentage of the practice include Roux-en-Y gastric bypass (⬃70%), sleeve gastrectomy (⬃7%), biliopancreatic diversion with duodenal switch (⬃5%), laparoscopic adjustable gastric banding (LAGB, ⬃3%), and other (revisional surgery, conversion surgery, LAGB removal, and partial gastric resection, ⬃15%). Individual-only patient/provider visit model Historically, all patients who underwent bariatric surgery within our multidisciplinary practice were scheduled for follow-up visits at 4 intervals within the first year after surgery: 1 month postoperatively (surgeon and registered dietitian [RD]); 3 months postoperatively (endocrinologist and RD); 6 months postoperatively (endocrinologist, RD,
221
and psychologist); and 12 months postoperatively (endocrinologist and RD). The individual-only patient/provider visits (IV) held at 3, 6, and 12 months postoperatively were replaced with the combined group and individual visits (CGVs) at the same follow-up points. The 1-month postoperative visit (surgeon and RD) was kept as an IV. CGV model The inclusion criteria for the present study was Rouxen-Y gastric bypass, biliopancreatic diversion with duodenal switch, or sleeve gastrectomy, performed within our practice for the management of medically complicated obesity, from February 1, 2010 to March 31, 2011. The exclusion criteria were LAGB (primarily because of differences in the postoperative diet protocol), LAGB removal only, complex revisional surgery, extensive postoperative complications, the need for a language interpreter, significant hearing impairment, and/or a strong aversion to group settings. Logistics and facilities Telephone contact with the patients was attempted by the bariatric program coordinator (BPC) 24 – 48 hours before each scheduled CGV. If the BPC made direct contact with the patient, attendance at their upcoming CGV was confirmed. On average, 5 patients were scheduled for each CGV. On the day of the CGV, the blood work was completed, and the patients were escorted to a wheelchair-accessible group education room. Each patient was seated in a bariatric chair and provided a folder containing the relevant postbariatric surgery education materials. Group nutrition education was provided by a RD. The RD used electronic presentation methods, food models, packages, and labels and guided the group discussion to enhance the education provided. At the conclusion of the nutrition education, the BPC (RN, RD) provided group physical activity education. After the group education, the patients met individually with an endocrinologist and a RD. Therefore, 2 patients were being seen individually at any given time. During these individual slots within the CGV, the providers identified and cared for the unique needs of each patient. If a provider believed a particular patient would be best served with an IV in the future, this was arranged by the BPC (Table 1). Patients not being seen individually remained in the group education room with the BPC. During this period, an on-line survey was completed by all patients. The BPC also led and moderated discussions on various bariatric surgeryrelated topics, including applicable web-based tools, options for postoperative support, and considerations related to physical activity and mental health.
222
P. A. Lorentz et al. / Surgery for Obesity and Related Diseases 8 (2012) 220 –224
Table 1 Data for individual patient/provider visits (former IV model) and combined group and individual patient/provider visits (new CGV model) Variable IV model Laboratory tests RD Endocrinologist Total time CGV model Laboratory tests Group nutrition education with RD Group physical activity education with BPC Alternating individual visits with RD and endocrinologist Total time
Time of day
Time needed/patient (min)
Total provider time for 5 patients (min)
7:30–8:00 AM 10:00–11:00 AM 3:00–4:00 PM 8.5 hr at clinic
5 60 60 125
25 300 300 625 (10.4 hr)
7:30–8:00 AM 8:30–9:15 AM 9:15–9.40 AM 9:50–11:30 AM 4 hr at clinic
5 45 25 20 95
25 45 25 200 295 (4.9 hr)
IV ⫽ individual-only patient/provider visit; RD ⫽ registered dietitian; CGV ⫽ combined group and individual visit; BPC ⫽ bariatric program coordinator.
Financial viability analysis To safeguard the financial viability of the CGV model, care was taken to balance the reduced per-patient charge with the volume of patients cared for. After a financial analysis was performed, it was determined that ⱖ4 postbariatric patients should be scheduled for each postbariatric CGV. In an effort to control the total time of the CGV and because of space limitations, the sessions were never scheduled with ⬎7 patients. Survey completion—patient acceptance and knowledge assessment
The remaining 113 patients (⬃34.9% of 324) had met ⱖ1 of the exclusion criteria and were scheduled for IVs. CGV model efficiency Our CGV model led to greater time efficiencies by reducing redundancies (primarily through group education) and by facilitating focused patient/provider visits. On average, 5 patients were seen within 4.9 provider hours compared with 10.4 hours using the IV model (Table 1). Financial considerations
Each CGV patient completed the on-line survey regarding their bariatric surgery process experience. The survey consisted of 10 multiple-response questions. Specifically, the questions were included to measure patient acceptance of the CGV model and to assess their level of understanding regarding the physical activity guidelines for the postbariatric surgery patient (Fig. 1).
Group nutrition education was charged as group medical nutrition therapy (MNT). Our institutional practice is to charge less per group MNT unit (1 U ⫽ 15 min) than for individual MNT units. For privately insured patients, the average billable charge for group MNT was 64% less than the equivalent individual MNT used in the IV model. For Medicare patients, the billable charge reduction was closer to 50%.
Attendance rate
Patient acceptance and attendance
The BPC maintained a spreadsheet of the CGV patients to monitor the attendance rates.
A total of 199, 142, and 38 postbariatric surgery patients at 3, 6, and 12 months after bariatric surgery completed our on-line survey, respectively. Of the 199 patients, 7 (⬍4%) were not comfortable using a computer to complete the survey. The patients were content with the group format, with 92.5%, 93%, and 88.6% of the patients at 3 months (184 of 199 surveys completed), 6 months (132 of 142 surveys completed), and 12 months (31 of 35 surveys completed) after bariatric surgery reporting being comfortable with the CGV setting, respectively (Fig. 1, question 4). The CGV model was well accepted, with 83%, 85.2%, and 75.7% of the patients at 3 months (161 of 194), 6 months (121 of 142), and 12 months (28 of 37), respectively. responding that they would not prefer to have only individual visits with their healthcare providers (Fig. 1, question 5). The rate of missed appointments/no-shows with the CGV model was also quite acceptable at ⬍10%.
Results Applicability of CGV model to bariatric surgery practice A total of 324 patients underwent bariatric surgery at our facility from February 1, 2010 to March 31, 2011. Of the 324 patients, 211 met the initial inclusion criteria for the CGV model. However, 12 patients (⬃3.7% of the 324) who met the initial inclusion criteria were unable to be seen using the CGV model for various reasons, including postoperative follow-up care pursued in their local area because of their great distance from our facility, the need to reschedule the CGV, or lost to follow-up. Therefore, 199 patients (⬃61.4% of 324) were included in the present study and were followed up using the CGV model.
Models for Postbariatric Surgery Follow-up Care / Surgery for Obesity and Related Diseases 8 (2012) 220 –224
223
Select Online Survey Quesons 4. Are you comfortable meeng in groups? o Yes o No If “No”, why not? (Free text box provided for paent comments) 5. Would you prefer to have only individual (rather than individual visits with some group sessions mixed in) visits with your healthcare providers? o No o Yes If “Yes”, please briefly explain (Free text box provided for paent comments) 8. Do you have any concerns which you would like addressed before leaving here today? o No o Yes If “Yes”, briefly explain (Free text box provided for paent comments) 10. Do you feel comfortable in knowing how much and what types of physical acvity are appropriate for you aer surgery? o Yes o No What types of physical acvity have you been doing since surgery? (Free text box provided for paent comments) Fig. 1. Select questions from on-line survey.
Knowledge assessment Patients attending the CGVs also expressed a sound understanding of the considerations relating to postoperative physical activity. Specifically, 98.5%, 98.6%, and 94.7% of the patients at 3 months (196 of 199), 6 months (140 of 142), and 12 months (36 of 38), respectively, reported feeling comfortable in knowing the quantity and types of physical activity appropriate for the postbariatric surgery patient (Fig. 1, question 10). Discussion To our knowledge, this is the first reported application of an SMA model to a well-defined postbariatric surgery patient population. Our new CGV model was suitable for the provision of postbariatric surgery follow-up care for approximately 60% of our patients. As previously reported, appropriate patient selection for participation in SMAs is a critical determinant of their success [6,7]. Our new CGV model was well-accepted, with most patients responding that they would not prefer to have only individual follow-up visits with their healthcare providers. Furthermore, the rate of missed appointments/no-shows was also quite acceptable, at ⬍10%. The positive effect of postbariatric surgery follow-up on patient outcomes has previously been reported [8,9]. The CGV model increased the efficiency by reducing the number of provider hours necessary to see a given quantity of patients. On average, 5 patients were seen within 4.9 provider hours compared with 10.4 hours with the IV model. Therefore, provider accessibility for other patients
within our practice was increased, more than offsetting the reduced group MNT charge of the CGV model. Financial viability was achieved with our average CGV size of 5 patients. Because of the lower group MNT charge, patients in the CGV model had a billable charge that was 50 – 64% less than that for similar patients seen in the IV model. These cost savings were passed on to the patients and the third-party payers. On the basis of our survey, ⬎94% of all patients seen in our CGVs reported feeling comfortable in knowing the amount and types of physical activity appropriate during the postoperative period. The importance of appropriate and adequate physical activity in the postbariatric surgery patient is well-established [10,11]. Developing and incorporating an SMA-based practice model, however, has some unique challenges and limitations. Significant resources are required to create and sustain such a model for a bariatric-related practice. An educational space equipped with bariatric accommodations (e.g., larger doorways, chair size, and seating capacity) is obligatory. Administrative staff are often needed to facilitate patient scheduling and to prepare the necessary educational materials. A BPC plays a pivotal role in the success of an SMA model for a bariatric-related practice. The BPC can provide the clinical judgment necessary to determine whether a given patient is appropriate for SMAs. During the actual SMA, the BPC facilitates the movement of patients through the SMA, in a coordinated and equitable fashion, and serves as a valuable patient resource. The BPC can also assist with post-SMA considerations, such as follow-up scheduling and
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medication prescription coordination and as a future point of contact for patients. Conclusion SMAs might have a valuable role in the care of the postbariatric surgery population, by offering a time- and cost-effective model for healthcare provision in a manner well-accepted by patients. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article. References [1] Livingston ED. The incidence of bariatric surgery has plateaued in the U.S. Am J Surg 2010;200:378 – 85. [2] Noffsinger EB. Running group visits in your practice. Newton, MA: Springer; 2009. [3] Carlson B. Shared appointments improve efficacy in the clinic. Manag Care 2003;12:46 – 8.
[4] American Academy of Family Physicians (AAFP). Group visits (shared medical appointments), 2005. Available from: http://www. aafp.org/online/en/home/practicemgt/quality/qitools/pracredesign/ january05.html. Accessed March 21, 2011. [5] Houck S, Kilo C, Scott JC. Improving patient care: group visits 101. Fam Pract Manag 2003;10:66 –78. [6] Masley S, Sokoloff J, Hawes C. Planning group visits for high-risk patients. Fam Pract Manag 2000;7:33–7. [7] Stein K. The group appointment trend gains traction: how dietetics fits into a new model of health care delivery. J Am Diet Assoc 2011;111:340 –53. [8] Shen R, Dugay G, Rajaram K, Cabrera I, Siegel N, Ren CJ. Impact of patient follow-up on weight loss after bariatric surgery. Obes Surg 2004;14:514 –19. [9] Pontiroli AE, Fossati A, Vedani P, et al. Post-surgery adherence to scheduled visits and compliance, more than personality disorders, predict outcome of bariatric restrictive surgery in morbidly obese patients. Obes Surg 2007;17:1492–7. [10] Evans RK, Bond DS, Wolfe LG, et al. Participation in 150 min/wk of moderate or higher intensity physical activity yields greater weight loss after gastric bypass surgery. Surg Obes Relat Dis 2007;3:526 –30. [11] Evans R, Wolfe L, Meador JG, Kellum JM, Maher JW. Gastric bypass surgery patients achieving suboptimal weight loss report less vigorous and total physical activity. Surg Obes Relat Dis 2009;5:S36.